pain the handbook
TRANSCRIPT
the handbook for people with pain
a resource guide 3rd edition
the handbook for people with pain a resource guide 3rd edition
Dear Member of the Pain Advocacy Community,
We are pleased to bring you the In the Face of Pain® “The Handbook for People with Pain.” Our goal is to provide you with a resource to help you and/or the one you care for on your day-to-day journey as you face challenges so often encountered by those who suffer from pain. This resource will provide you with a variety of information, ideas, and tools that we encourage you to use and share with others.
We would like to acknowledge those organizations which generously allowed us to share their resources with you and we hope “The Handbook for People with Pain” will give you the inspiration and tools to support your pain advocacy efforts. There is no better time to take an active role in advocating for those living with pain.
To order free copies of this Handbook go to www.inthefaceofpain.com/resources/resource-guide.
Sincerely,
Your Purdue Healthcare Alliance Development Team
Pamela Bennett, RN, BSN Craig R. Engesser, BSJ Executive Director Associate Director Kimberley Tiller, RN, MPH Gina Barbarotto, MS, MBA Associate Director Associate Director
Your Pain Assessment Tools ........................................................................3
Pain Scales ....................................................................................4 – English & Spanish
Daily Pain Logs ..............................................................................6
Resources .................................................................................... 10
Your Treatment Plan ...................................................................................13
Communicating with Your Healthcare Team .................................. 14
Be More Involved in Your Health Care ............................................15
Questions to Ask Your Healthcare Team ........................................ 16
Your Personal Care Team Pocket Card ............................................17
Your Treatment Plan ..................................................................... 19
Medication Adherence, Safety and Disposal .................................20
Your Quick Reference Medication Pocket Card ..............................27
Resources ....................................................................................29
A Healthier You .......................................................................................... 31
Nutrition ...................................................................................... 32
Physical Activity ...........................................................................34
Stress .......................................................................................... 35
Sleep ...........................................................................................40
Resources ....................................................................................42
Focus on Caregiving ................................................................................... 43
Family Caregivers .........................................................................44
Caring for Those Who Suffer From Pain ......................................... 45
Caring for Those at End of Life.......................................................46
Caring Conversations - English & Spanish ..............................46
Caring for the Caregiver ................................................................ 47
Tips for the Caregiver - English & Spanish ..............................48
Resources ....................................................................................49
Special Considerations for Seniors .............................................................51
Focus on Clinical Trials ............................................................................... 55
Focus on Finances ...................................................................................... 59
Purdue Pharma L.P. Resources ..................................................................66
Table of Contents
Table of Contents
2
Your Pain Assessment ToolsThe tools included in this section are meant to help you keep track of your pain as well as teach you how to communicate that information to your Healthcare Team.
Here is what you will find:
1. Pain Scales • English & Spanish
2. Pain Logs
3. Resources
Your Pain Asessm
ent Tools
4
English
Spanish
Patient Name: ___________________________________________________ Date: ________________
0-10 Numeric Pain Intensity Scale*
* If used as a graphic rating scale, a 10-cm baseline is recommended. From: Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline No. 1. AHCPR Publication No. 92-0032; February 1992. Agency for Healthcare Research & Quality, Rockville, MD; pages 116-117.
0 1 2 3 4 5 6 7 8 9 10No
painModerate
painWorst
possiblepain
0 1 2 3 4 5 6 7 8 9 10No tiene dolor
No painTiene un terrible dolor
Terrible pain
Por favor señale el número que mejor describe su dolor.Please point to the number that best describes your pain.
May be duplicated for use in clinical practice. As appears in McCaffery M, Pasero C: Pain: Clinical manual, pp. 68-73, 1999, Mosby, Inc.
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Patient Name: ________________________________________________ Date: _______________
Wong-Baker FACES™ Pain Rating Scale Instructions for Usage
Explain to the person that each face is for a person who has no pain (hurt) or some, or a lot of pain.
Face 0 doesn’t hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little bit more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.
Ask the person to choose the face that best describes how much pain he has.
Wong-Baker Foundation www.wongbakerFACES.org ©1983 Wong-Baker FACESTM Foundation. Used with permission.
0 2 4 6 8 10 No Hurts Hurts Little Hurts Even Hurts Hurts Hurt Little Bit More More Whole Lot Worst
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Live Better with Pain Log
Many things can affect your pain. These can include stress, sleep, money worries, and even the weather. When you and your doctor both understand what makes your pain worse, you can begin to work together on ways to reduce or deal with your pain “triggers.”
7
On these pages, mark the number that most closely matches your experience with each item over the last several weeks.
8
Live Better with Pain Log
(continued)
9
Pain DiaryDa
te &
Ti
me
0
1 2
3 4
5 6
7 8
9 10
Pain
scor
e(0
to 1
0)No
n-dr
ug
tech
niqu
es
I trie
d
How
long
the
pain
last
edO
ther
not
esW
hat I
was
doi
ng
whe
n it
bega
nNa
me
and
amou
nt o
f m
edic
ine
take
nW
here
pai
n is
and
how
it
feel
s (a
che,
shar
p, th
robb
ing,
sh
ootin
g, ti
nglin
g, e
tc.)
No p
ain
Mod
erat
e pa
inW
orst
pai
n
you’
ve e
ver h
ad
Adapted from the American Cancer Society
10
American Cancer Society 800-ACS-2345 (800-227-2345) www.cancer.org
American Chronic Pain Association 800-533-3231 www.theacpa.org
American Society of Law, Medicine and Ethics 617-262-4990 www.aslme.org
Amputee Coalition of America 888-267-5669 www.amputee-coalition.org
Arthritis Foundation 800-283-7800 www.arthritis.org
C-Change 800-830-1827 www.c-changetogether.org
Center for Practical Bioethics 800-344-3829 www.practicalbioethics.org
Citizen Advocacy Center 202-462-1174 www.cacenter.org
Dia de la Mujer Latina, Inc. 281-489-1111 www.diadelamujerlatina.org
Disabled American Veterans 877-426-2838 www.dav.org
Ehlers-Danlos National Foundation 703-506-2892 www.ednf.org
Ehlers-Danlos Syndrome Network C.A.R.E.S 262-514-2851 www.ehlersdanlosnetwork.org
Hospice Foundation of America 800-854-3402 www.hospicefoundation.org
Intercultural Cancer Council 713-798-4614 www.iccnetwork.org
Interstitial Cystitis Association 800-435-7422 www.ichelp.org
Lance Armstrong Foundation 877-236-8820 www.livestrong.org
The Leukemia & Lymphoma Society 800-955-4572 www.leukemia-lymphoma.org
National Family Caregivers Association 800-896-3650 www.thefamilycaregiver.org
National Fibromyalgia & Chronic Pain Association 801-200-3627 www.fmcpaware.org
National Organization for Rare Disorders 800-999-6673 www.rarediseases.org
National Stroke Association 800-STROKES (800-787-6537) www.stroke.org
National Vulvodynia Association 301-299-0775 www.nva.org
National Women’s Health Resource Center 877-986-9472 www.healthywomen.org
Pancreatic Cancer Action Network 877-272-6226 www.pancan.org
Patient Alliance for Neuroendocrineimmune Disorders Organization for Research and Advocacy 305-441-1591 www.pandoranet.info
Patient Advocate Foundation 800-532-5274 www.patientadvocate.org
Patient Resources
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Prostate Net 888-477-6763 www.prostate-online.org
Power of Pain 804-657-7246 www.powerofpain.org
Reflex Sympathetic Dystrophy Syndrome Association 877-662-7737 www.rsds.org
Sickle Cell Disease Association of America 800-421-8453 www.sicklecelldisease.org
Society for Women’s Health Research 202-223-8224 www.swhr.org
Susan G. Komen for the Cure 877-465-6636 www.komen.org
TMJ Association 262-432-0350 www.tmj.org
U.S. Pain Foundation 800-910-2462 www.uspainfoundation.org
Patient Resources
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Your Treatment Plan
Your Treatment Plan You are the expert on your pain!
You are a partner and the key source of information for your Healthcare Team, but identifying the right providers and communicating information can sometimes be a challenge.
The next few pages will provide information on:
• Communicating with your Healthcare Team
• Your Treatment Team
• Your Treatment Plan
• Medication Adherence, Safety and Disposal
• Your Medication Card
• Resources and organizations that may be helpful in identifying members to add to your Healthcare Team
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Communication
Making healthcare-related decisions can be very complicated and sometimes overwhelming. It is a time when we are forced to not only assess our own values, strengths and priorities but also to communicate these things. As you know, communication does not come easily for everyone; however, it is a skill that can be learned and improved upon over time.
Communication is a very broad term and includes both giving and receiving messages. When you are trying to give information to your healthcare professional remember to be:
• prepared
• concise
• considerate
See page 16 for possible questions to help you prepare for your visit.
While both aspects may be challenging, the receiving of messages, i.e. listening, is what most of us think we are really good at but that’s not always the case. Do you find yourself finishing others’ sentences or formulating a response before the other person is finished speaking? If so, perhaps you’re not listening as well as you think.
Active listening takes work but is invaluable in the com-munication process. Active listening is defined as: making a conscious effort to hear not only the words that another person is saying but, more importantly, trying to under-stand the complete message being sent.1
The five key elements to active listening are:1
1. Pay attention
2. Show that you are listening
3. Provide feedback
4. Defer judgment
5. Respond appropriately
As with any other activity or skill, it can be improved but it takes practice. Perhaps if we practice our listening skills it will inspire others to follow suit, so let’s make a special effort to listen with our eyes, ears and heart!
1. www.mindtools.com/CommSkll/ActiveListening.html
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Be More Involved In Your Health Care: Tips For Patients
This brochure gives you tips to use before, during, and after your medical appointment to make sure you get the best possible care. One way you can make sure you get good quality health care is to be an active member of your health care team. Patients who talk with their doctors tend to be happier with their care and have better medical results.
http://www.ahrq.gov/consumer/beinvolved.pdf
Este folleto le brinda consejos que puede aplicar antes, durante y después de su cita médica, para asegurarse de que recibe la mejor atención posible. Una forma de asegurarse de que recibe una atención médica de buena calidad es
convertirse en miembro activo de su equipo de atención médica.
Los pacientes que hablan con sus médicos tienden a estar más satisfechos de la atención que reciben y logran mejores resultados médicos.
www.ahrq.gov/consumer/beinvolvedsp.pdf
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?Questions to Ask Your Healthcare Team
1. What is causing my pain?
2. What can be done to make it better?
3. What can I do to help manage my pain?
4. What is the treatment plan?
5. Please tell me about the medications you prescribed for me:
1. What are the medications for and when do I take them?
2. What effects should I expect?
3. What should I do if I have side effects?
4. Are there any risks associated with these medications?
5. What if the medicine does not help?
6. How should I store and dispose of unused medicine?
6. What are the goals for my treatment plan?
7. When will we evaluate the effectiveness of my treatment plan?
For examples of more questions go to the Agency for Healthcare Research and Quality (AHRQ):
www.ahrq.gov/questionsaretheanswer
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Resource For Patients & Caregivers
Pain
Sp
ecia
list
Pain
Sp
ecia
list
Prim
ary
Care
Pr
ofes
sion
al
Prim
ary
Care
Pr
ofes
sion
al
Soci
al
Wor
ker
Soci
al
Wor
ker
Phar
mac
y
Phar
mac
y
Phar
mac
ist
Phar
mac
ist
Nurs
e
Nurs
e
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
Personal Care Team Pocket Card Personal Care Team Pocket Card
Patient Information
Name
Telephone Number(s)
Date of Birth
Allergies
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Patient Information
Name
Telephone Number(s)
Date of Birth
Allergies
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
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Cler
gy
Cler
gy
Oth
er
Oth
er
Psyc
holo
gist
Psyc
holo
gist
Chiro
prac
tor
Chiro
prac
tor
Fitn
ess
Cent
er
Fitn
ess
Cent
er
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Insurance Information
Name
Telephone Number(s)
Policy Number
Emergency Contact Information
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Insurance Information
Name
Telephone Number(s)
Policy Number
Emergency Contact Information
Mas
sage
Th
erap
ist
Mas
sage
Th
erap
ist
Acup
unct
uris
t
Acup
unct
uris
t
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – – – – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – – – – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – – – – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
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It’s important that you and your Healthcare Team set mutually agreed upon goals for your pain treatment. These goals should be realistic and re-evaluated often.
Goals for treatment of your pain:
1. Improve function so that I can now _____________________________________________
2. Pain decreased from ___________________________ to __________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
A comprehensive and individualized treatment plan may include many techniques. My treatment plan includes:
Most of these treatment plan components will be addressed later in this Handbook. You will also be provided with numerous websites where you can find more information on all of the above topics.
Your Treatment Plan
Physical Modalities
• Physical Therapy (TENS, ultra sound, cold/heat)
•Occupational Therapy (simplify activities of daily living, assistive devices)
•Massage
•Other
Medication Management (see Medication pocket card)
Psychosocial
•Biofeedback
•Stress management
•Support groups
•Other
Integrative Approaches
•Yoga
•Tai-chi
•Acupuncture
•Other
Nutrition
•___ lb weight gain
•___ lb weigh loss
•Make healthier choices
Physical Activity
•___ minutes of physical activity ___/week
Sleep Restoration
•___ hours of sleep/night
Other
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1. National Community Pharmacists Association and Pharmacists for the Protection of Patient Care Adherence Survey 2006.
2. New England Healthcare Institute, “Thinking Outside the Pillbox,” available at www.nehi.net/news/press_releases/110/nehi_research_shows_patient_medication_nonadherence_costs_ health_care_system_290_billion_annually
3. L Osterberg and T Blaschke, “Adherence to Medication,” New England Journal of Medicine 4 Aug 2005: 4877-97.
4. Switzerland, World Health Organization, Adherence to Long-Term Therapies – Evidence for Action, (Geneva: WHO, 2003).
5. American College of Physicians, “Costs and Quality Associated with Treating Medicare Patients with Multiple Chronic Conditions,” 18 May 2009 www.acponline.org/advocacy/events/state_of_healthcare/costs_quality.pdf
Medication Adherence
The quote by former US Surgeon General, C. Everett Koop, “Drugs don’t work in patients that don’t take them,” sums it up nicely, but we all know there are many reasons why people don’t always take their medication.
The National Consumers League (NCL) did extensive research and identified the need to improve medication adherence. Some of their findings included:
• Nearly three out of four Americans report that they do not always take their medications as directed:1
• Failure to take medications as instructed isn’t just an individual’s problem; it impacts all of us – as patients, caregivers, employers, healthcare providers, researchers, and taxpayers.
• Nonadherence costs dollars and lives:
• It is estimated that nonadherence costs almost $300 billion annually.2
• 33-69% of medication-related hospital admissions are linked to nonadherence.3
• The World Health Organization estimates that certain adherence interventions generate a cost-to-savings ratio of 1:10. Improved medication adherence may have a far greater impact on health than any improvements in specific medical treatments.4
• Chronic Conditions:
• 133 million Americans are affected by at least one chronic condition.5
• By 2020, this number will increase to 157 million.5
NCL has used these findings to develop a National Medication Adherence Campaign. This multi-media campaign is intended to improve public health by raising consumer awareness of the importance of good medication adherence. For more information on this campaign please go to www.scriptyourfuture.org.
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YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
For financial or other reasons, have you not filled an initial prescription?
For financial or other reasons, have you not refilled a pre- scription that your health care provider wanted you to take?
Have you ever forgotten to take your medications as prescribed?
Have you ever stopped, skipped, or delayed taking a medication to save it for future use?
Have you ever stopped taking your medication without telling your health care provider?
When you feel better, do you sometimes stop or skip doses of your medication?
Have you ever taken someone else’s medication?
If you have answered “yes” to any of the above questions, you are probably not taking your medication correctly, which may affect your health.
Adherence does not mean just taking the medications. For medications to do their job properly, you need to take the medications at the right doses, time, purpose and for the proper length of therapy. If for any reason you find yourself unable to do this, please have a discussion with your health care provider. Perhaps there are alternatives and solutions for your treatment plan that are acceptable to both you and your provider.
*Adapted from PrescriptionSolutions®, A UnitedHealth Group Company www.hopbenefits.com/pdfs/2009/MedicationCompliance.pdf
Medication Adherence Quiz
QUESTION ANSWER (YES OR NO)
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Medication Safety
No one can argue that medicines play an important role in treating certain conditions and diseases, but they must be taken with care. By being an informed consumer and being involved in your healthcare, you can help decrease the risks and get the most benefits from your medicine.
You can do this by following the Food and Drug Administration’s (FDA) recommendation to make medicine use SAFER:
• Speak up
• Ask questions
• Find the facts
• Evaluate your choices
• Read the label and follow directions
The Agency for Healthcare Research and Quality (AHRQ) and The National Council on Patient Information and Education (NCPIE) worked together to create a brochure called “Your Medicine: Be Smart. Be Safe.” This brochure is very helpful and is available in both English & Spanish at
www.ahrq.gov/consumer/safemeds/yourmeds.pdf and
www.ahrq.gov/consumer/safemedsp/yourmedssp.pdf
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Safe Storage of Medication
Safeguarding Prescription Medicines in Your Home: Your Personal Responsibility
When used as directed, prescription medicines can play a critical role in treating a range of debilitating diseases and conditions. Yet many don’t realize the responsibilities that come with having prescription medicine – especially a controlled substance – in the home.
Unused and easily accessible medicines have the potential to be misused and abused, particularly by teens. According to the Centers for Disease Control and Prevention, the prescription medicines most commonly abused by youth include pain relievers, tranquilizers, stimulants and depressants.1
Properly storing and disposing of prescription medicines in your home is an important way to reduce the risk of their misuse and abuse by family members and others.
The reality of prescription medicine misuse and abuse
• 70% of people 12 and older who abused pain relievers in 2007-2008 say they got them from a friend or relative.2
• 1 in 5 U.S. high school students report abusing a prescription medication at least once in their lives.3
• More teens abuse prescription drugs than any illicit drug except marijuana.4
Storing Your Prescription Medicine
Medicine that is not properly secured could:
• be taken or stolen from the home by someone for whom it is not intended
• be damaged by being stored in an unsuitable place
• inadvertently poison children or pets
1, 2. Substance Abuse and Mental Health Services Administration 3. Partnership for a Drug Free America 4. Office of National Drug Control Policy
*Content obtained from the Safeguard My Meds brochure: www.rxsafetymatters.org
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The Do’s and Don’ts of Safe Medicine Storage
3 DO store medicines in a cool, dry place
3 DO lock up medicines that are at risk for being abused – ask your community pharmacist or other healthcare professional if the prescription medicine prescribed to you or a household member has abuse potential
3 DO store medicines in original containers – the label on the bottle provides important information about the medicine such as who it is prescribed for and the date it was dispensed
3 DO keep track of how many pills you have during the course of treatment
3 DO discard medicines that are no longer needed or that have expired
7 DON’T leave medicines in places that are easily accessible for children
7 DON’T share medicine with someone for whom it was not intended
7 DON’T repackage medicine in unmarked containers
7 DON’T leave medicines that are at risk for being abused in plain sight or in places that aren’t secure
7 DON’T take medicines in front of children as they often mimic the behavior of adults
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Lo que SÍ debe y NO debe hacer al guardar medicamentos
3 SÍ mantenga los medicamentos en un lugar fresco y seco.
3 SÍ guarde bajo llave los medicamentos que puedan ser usados de forma abusiva. Pregúntele al farmaceuta de su comunidad o a otro profesional de la salud si el medicamento que le prescribieron a usted o a cualquier otro habitante de su hogar puede ser usado de forma abusiva.
3 SÍ conserve los medicamentos en sus empaques originales. La etiqueta que aparece en el frasco contiene información importante sobre el medicamento, como el nombre del paciente y la fecha en que se le entregó.
3 SÍ lleve la cuenta de la cantidad de pastillas que toma durante el tratamiento.
3 SÍ deseche los medicamentos que ya no necesita o que ya se han vencido.
7 NO deje los medicamentos en lugares de fácil acceso para los niños.
7 NO comparta sus medicamentos con personas a quienes no les fueron prescritos.
7 NO pase sus medicamentos a envases que no estén debidamente identificados.
7 NO deje sus medicamentos que tengan riesgo de abuso a la vista de todos o en lugares que no sean seguros.
7 NO tome medicamentos delante de los niños. Muchas veces ellos imitan los comportamientos de los adultos.
1,2. Administración de Salud Mental y Abuso de Sustancias 3. Alianza para una America Libre de Drogas 4. Oficina de Política Nacional de Control de Drogas *Content obtained from the Safeguard My Meds brochure: www.rxsafetymatters.org
Almacenamiento seguro de los medicamentos
Guardar en un lugar seguro / Los medicamentos prescritos en casa: Su responsabilidad Cuando se utilizan de la manera adecuada, los medicados prescritos pueden jugar un papel muy importante en el tratamiento de un gran número de enfermedades y de otros problemas relacionados con la salud. Sin embargo, muchas personas no se dan cuenta de la responsabilidad que significa tener en casa un medica-mento prescrito, especialmente cuando se trata de una sustancia controlada.
Los medicamentos no utilizados que están al alcance de la mano pueden ser utilizados de forma abusiva por otras personas, especialmente por adolescentes. Según los Centros para el Control y la Prevención de Enfermedades, los medicamentos prescritos de los que abusan con más frecuencia los jóvenes son los analgésicos, los tranquilizantes, los estimulantes y los antidepresivos.1
Guardar y desechar los medicamentos prescritos de manera apropiada en su casa es importante para reducir el riesgo de su mal uso y abuso por parte de los demás miembros de la familia o de cualquier otra person.
La realidad de los medicamentos prescritos: Mal uso y abuso• El 70% de las personas de 12 años o más, que abusaron de analgésicos en 2007-2008 afirman que los consiguieron a través de un amigo o familiar.2
• 1 de cada 5 estudiantes de secundaria en Estados Unidos han reportado el abuso de un medicamento prescrito por lo menos una vez en su vida.3
• Los adolescentes abusan con mayor frecuencia de los medicamentos prescritos que de cualquier otra droga ilícita, exceptuando la marihuana.4
Cómo guardar sus medicamentos prescritosLos medicamentos que no se guardan de forma segura podrían:
• Ser tomados o robados de su casa por alguien a quien no le correspondan
• Deteriorarse por estar guardados en un lugar inadecuado
• Envenenar accidentalmente a niños o mascotas
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Safe Disposal
Disposal
What should you do with unused or expired medication? There is a lot of conflicting information out there, but the bottom line is that these medicines should be disposed of properly to avoid harm. According to the Food and Drug Administration (FDA) almost all medicines can be thrown away in the household trash after mixing them with some unpalatable substance (e.g., coffee grounds) and sealing them in a container.
However, certain medicines may be especially harmful if they are used by someone other than the person the medicine was prescribed for. For this reason, a few medicines have special disposal directions that indicate they should be flushed down the sink or toilet after the medicine is no longer needed. If you dispose of these medicines down the sink or toilet, they cannot be accidently used by children, pets, or anybody else. The following is a link to a document developed by the FDA and describes in great detail the agency’s recommendations on the disposal of prescription medication.
www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm
www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html
27 Med
icat
ion
Reco
rd
Med
icatio
n Na
me &
Stre
ngth
Do
se
# Do
ses
Time
# Tim
es/D
ay
Date
Sta
rted
Reas
on fo
r Tak
ing
Quick Reference Medication Pocket Card
Quick Reference Medication Pocket Card
Med
icat
ion
Reco
rd
Med
icatio
n Na
me &
Stre
ngth
Do
se
# Do
ses
Time
# Tim
es/D
ay
Date
Sta
rted
Reas
on fo
r Tak
ing
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
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Patient Information
Name
Telephone Number(s)
Date of Birth
Allergies
Healthcare Professional
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Pharmacy
Name
Telephone Number(s)
Insurance Information
Name
Telephone Number(s)
Policy Number
Emergency Contact Information
Name
Telephone Number(s)
Patient Information
Name
Telephone Number(s)
Date of Birth
Allergies
Healthcare Professional
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Name
Telephone Number(s)
Pharmacy
Name
Telephone Number(s)
Insurance Information
Name
Telephone Number(s)
Policy Number
Emergency Contact Information
Name
Telephone Number(s)
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – – – – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – – – – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
– – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – – – – – – – – – – – – – – – –– – – – – Fold Here if Desired – – – – – – – – – – – – – –– – – – –
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Nurses
American Academy of Nurse Practitioners 512-442-4262 www.aanp.org
American College of Nurse Practitioners 703-740-2529 www.acnpweb.org
American Society for Pain Management Nursing 888-342-7766 www.aspmn.org
Association of Rehabilitation Nurses 800-229-7530 www.rehabnurse.org
Hospice and Palliative Nurses Association 412-787-9301 www.hpna.org
Nurse Practitioner Healthcare Foundation 425-861-0911 www.nphealthcarefoundation.org
National Association Directors of Nursing Administration in Long Term Care 800-222-0539 www.nadona.org
Oncology Nursing Society 866-257-4667 www.ons.org
Pharmacists
American Pharmacists Association 800-237-2742 www.pharmacist.com
American Society of Consultant Pharmacists 800-355-2727 www.ascp.com
National Community Pharmacists Association 703-683-8200 www.ncpanet.org
Physicians
American Academy of Family Physicians 800-274-2237 www.aafp.org
American Academy of Hospice and Palliative Medicine 847-375-4712 www.aahpm.org
American Academy of Neurology 800- 879-1960 www.aan.com
American Academy of Pain Medicine 847-375-4731 www.painmed.org
American Academy of Physical Medicine and Rehabilitation 847-737-6000 www.aapmr.org
American College of Osteopathic Family Physicians 800-323-0794 www.acofp.org
American College of Physicians 800-523-1546 www.acponline.org
American College of Rheumatology 404-633-3777 www.rheumatology.org
American Geriatrics Society 212-308-1414 www.americangeriatrics.org
American Medical Directors Association 800-876-2632 www.amda.com
American Medical Association 800-621-8335 www.ama-assn.org
American Osteopathic Association 800-621-1773 www.osteopathic.org
(continued)
Healthcare Professional Resources
30
American Psychiatric Association 888-35-77924 www.psych.org
American Society of Anesthesiologists 847-825-5586 www.asahq.org
American Society of Clinical Oncologists 888-282-2552 www.asco.org
American Society of Regional Anesthesia and Pain Medicine 847-825-7246 www.asra.com
American Academy of Orthopaedic Surgeons 847-823-7186 www.aaos.org
Social Workers
Association of Oncology Social Work 215-599-6093 www.aosw.org
National Association of Social Workers 202-408-8600 www.naswdc.org
Other/Multidisciplinary
American Academy of Pain Management 209-533-9744 www.aapainmanage.org
American Academy of Physician Assistants 703-836-2272 www.aapa.org
American Chiropractic Association 703-276-8800 www.acatoday.org
American Occupational Therapy Association 301-652-2682 www.aota.org
American Physical Therapy Association 800-999-2782 www.apta.org
American Pain Society 847-375-4715 www.ampainsoc.org
Case Management Society of America 800-216-2672 www.cmsa.org
National Hospice and Palliative Care Organization 703-837-1500 www.nhpco.org
University of Wisconsin Pain and Policy Study Group 608-262-7662 www.painpolicy.wisc.edu
Mental Health America 800-969-6642 www.nmha.org
U.S. Food and Drug Administration 888-463-6332 www.fda.gov
(continued from previous page)
Healthcare Professional Resources
A Healthier YouIf asked the question – “What do you hold most dear in your life?” – most of us would answer our family and our health. Yet, most people take better care of their cars than they do their bodies.
There are many factors that influence our physical and mental health and overall well-being. A few of these factors include:
•Proper nutrition • Physical activity • Stress management • Adequate sleep
This list is by no means exhaustive but will serve as a starting point in the discussion of the foundation of health as well as an integrated approach to pain management.
As you embark on your journey to a “healthier you” remember to prioritize, set limits and pace yourself!
A Healthier You
32
Nutrition
Good nutrition is vital to good health. Specific diseases and conditions linked to poor diet include cardio-vascular disease, hypertension, dyslipidemia, type 2 diabetes, overweight and obesity, osteoporosis, constipation, diverticular disease, iron deficiency anemia, oral disease, malnutrition, and some cancers. (You will notice that many of these conditions have a pain component).
Each major food group provides a variety of nutrients, so it’s important to include all food groups in your daily eating plan while not exceeding recommended caloric intake. There is a plethora of information out there but identifying a food plan that’s right for you often presents a challenge.
The next few pages will identify just a few resources that may provide some insight on dietary needs and nutrition guidance from the United States Department of Agriculture.
*Please consult with your Healthcare team before starting a diet. Also check with your pharmacist for food/medication interactions.
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34
• Have stronger muscles and bones
• Stay at or get to a healthy weight
• Be with friends or meet new people
• Enjoy yourself and have fun
• Have high blood cholesterol
• Have a stroke
2
Why Is Physical Activity Important?
According to the United States Department of Agriculture, regular physical activity can produce long term health benefits. People of all ages, shapes, sizes, and abilities can benefit from being physically active. The more physical activity you do, the greater the health benefits.
Being physically active can help you:
• Increase your chances of living longer
• Feel better about yourself
• Decrease your chances of becoming depressed
• Sleep well at night
• Move around more easily
When you are not physically active, you are more likely to:
• Get heart disease
• Get type 2 diabetes
• Have high blood pressure
Physical activity and nutrition work together for better health. Being active increases the amount of calories burned. As people age their metabolism slows, so maintaining energy balance requires moving more and eating less.
Some types of physical activity are especially beneficial:
• Aerobic activities make you breathe harder and make your heart beat faster. Aerobic activities can be moderate or vigorous in their intensity. Vigorous activities take more effort than moderate ones. For moderate activities, you can talk while you do them, but you can’t sing. For vigorous activities, you can only say a few words without stopping to catch your breath.
• Muscle-strengthening activities make your muscles stronger. These include activities like push-ups and lifting weights. It is important to work all the different parts of the body – your legs, hips, back, chest, stomach, shoulders, and arms.
• Bone-strengthening activities make your bones stronger. Bone strengthening activities, like jumping, are especially important for children and adolescents. These activities produce a force on the bones that promotes bone growth and strength.
• Balance and stretching activities enhance physical stability and flexibility, which reduces risk of injuries. Examples are gentle stretching, dancing, yoga, martial arts, and t’ai chi.1
1. United States Department of Agriculture www.ChooseMyPlate.gov/physical-activity/why.html
2. United States Department of Agriculture www.choosemyplate.gov/food-groups/downloads/resource/MyPyramidBrochurebyIFIC.pdf
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Stress
Stress means something different to each of us, but one thing is for certain and that is most of us have more firsthand experience with it than we care to admit.
Scientists have been studying the psychological and physical impact of stress for decades. It is beyond the scope of this resource to provide you with an in-depth review of all the information available. What will follow is a brief summary of some of the most important aspects of stress, how it affects our health and what we can do to try to deal with the aftermath.
When we encounter an event that is perceived as harmful or threatening, it triggers a chain reaction in the brain which you may have heard referred to as the flight-or-fight response. During these threatening and stressful moments, whether emotional or physical, our bodies experience changes such as an increase in blood pressure, heart rate and sweating and also constriction of peripheral blood vessels.
How many times during the course of the day, week, month and year do you experience stress? Think about the impact this must be having on your body.
When stressful events occur, we spend so much time and energy trying to deal with the situation we draw our efforts away from other aspects of life that need our attention. As a result, we often let our unhealthy habits resurface. For example, people may lose sleep, eat poorly, stop exercising and increase smoking and alcohol consumption. These behaviors are unhealthy and put a tremendous strain on our bodies, not to mention make us less likely to deal with stress effectively.
Stress is inevitable but how you deal with it is your choice. There are many coping styles such as: laughter, prayer, meditation, and social support, just to name a few.
What works for one person may not work for another. Reflect on your own coping style. If it’s not working so well for you, perhaps it’s time to try something new.
See the next page to take the Recent Life Changes Questionnaire.
36
Health
An illness or injury that kept you in bed for more than a week or sent you to the hospital 74 █An illness or injury that was less serious than above 44 █Major dental work 26 █Major change in eating habits 27 █Major change in sleeping habits 26 █Major change in your usual type and/or amount of recreation 28 █
Work
Change to a new type of work 51 █Change in your work hours or conditions 35 █More work responsibilities 29 █Fewer work responsibilities 21 █A promotion 31 █A demotion 42 █A transfer 32 █Trouble with your boss 29 █Trouble with your coworkers 35 █Trouble with those you supervise 35 █Other work troubles 28 █Major business readjustment 60 █Retirement 52 █Laid off 68 █Fired 79 █Took a course to help your work 18 █
Home and family
Major change in living conditions 42 █Move within same city or town 25 █Move to different town, city, or state 47 █Change in family get-togethers 25 █Major change in health or behavior of a family member 55 █Marriage 50 █Pregnancy 67 █Miscarriage or abortion 65 █Birth of a child 66 █Adoption of a child 65 █Relative moves in with you 59 █Spouse begins or stops work 46 █Child leaves home to attend college 41 █Child leaves home due to marriage 41 █Child leaves home for other reasons 45 █Change in arguments with spouse 50 █Problems with relatives or in-laws 38 █Parents divorce 59 █A parent remarries 50 █Separation from spouse due to work 53 █Separation from spouse due to marital difficulties 76 █Divorce 96 █Birth of grandchild 43 █Death of spouse 119 █Death of child 123 █Death of parent 100 █Death of a brother or sister 102 █
Recent Life Changes Questionnaire (RLCQ)
The following Recent Life Changes Questionnaire (RLCQ)1 is a list of possible “normal” life events. Simply add up the numbers on the right of each event that has occurred in your life in the last 6 months. A 6-month score of 300 or more, or a 12-month score of 500 or more, indicates high stress in your life.
1. Miller, M. A. and Rahe, R.H. Life Changes Scaling for the 1990’s. Journal of Psychosomatic Research, Vol. 43, No. 3,pp. 279-292, 1997.
37
Personal and social
Change in personal habits 26 █Beginning or ending school 38 █Change of school or college 35 █Change in political beliefs 24 █Change in religious beliefs 29 █Change in social activities 27 █Vacation 24 █New, close personal relationship 37 █Engagement to marry 45 █Girlfriend or boy friend problems 39 █Sexual difficulties 44 █“Falling out” of a close personal relationship 47 █An accident 48 █Minor violation of the law 20 █Being held in jail 75 █Death of a close personal friend 70 █Major decision about immediate future 51 █Major personal achievement 36 █
Recent Life Changes Questionnaire (RLCQ) continued
Financial
Major increase in income 38 █Major loss of income 60 █Investment and/or credit difficulties 56 █Loss/damage to personal property 43 █Moderate purchase 20 █Major purchase 37 █Foreclosure on mortgage or loan 58 █
Health subtotal
Work subtotal
Home and family subtotal
Personal and social subtotal
Financial subtotal
TOTAL
38
Stress Management Techniques
Make an effort to stop negative thoughts:
• Plan some fun.
• Refocus the negative into the positive.
• Take a break.
• Think positively.
Physical activity:
• Start a physical activity program. Most experts recommend doing 20 minutes of aerobic activity three times per week.
• Decide on a specific time, type, amount, and level of physical activity. Fit this time into your schedule so it can be part of your routine.
• Find a buddy to exercise with – it is more fun and it will encourage you to stick with your routine.
• You do not have to join a gym – 20 minutes of brisk walking outdoors will do the trick.
Nutrition:
• Plan to eat foods that improve your health and well-being. For example, increase the amount of fruits and vegetables you eat.
• Use ChooseMyPlate.gov to help you make healthy food choices.
• Eat the right amount of food on a regular schedule.
39
Social support:
• Make an effort to interact socially with people. Even though you feel stressed, you will be glad to meet your friends, if only to get your mind off of things.
• Nurture yourself and others.
• Reach out to other people.
• Support Groups
Relaxation:
• Learn about and try using one or more of the many relaxation techniques, such as guided imagery, listening to music, or practicing yoga or meditation. One or more of these techniques should work for you.
• Listen to your body.
• Take a mini retreat.
• Take time for personal interests and hobbies.
Talk with Your Health Care Professional:
If these stress management techniques do not work for you, there are professionals, such as licensed social workers, psychologists, and psychiatrists, who can help. Schedule time with one of these mental health professionals to help you learn stress management strategies, including relaxation techniques.
Source: National Library of Medicine, MedlinePlus. Available at: www.nlm.nih.gov/medlineplus/ency/article/001942.htm
40
Sleep
Pain is one of many detractors from a good night’s sleep. The National Sleep Foundation reports that 2 ⁄3 of chronic pain sufferers experience sleep problems. When a chronic pain sufferer experiences interrupted sleep, a vicious cycle ensues – sleep disruption caused by chronic pain exacerbates the pain, which in turn interrupts sleep.1
Like eating well and being physically active, getting a good night’s sleep is vital to your well-being. Until the 1950s, most people thought of sleep as a passive, dormant part of our daily lives. We now know that our brains are very active during sleep. Moreover, sleep affects our daily functioning and our physical and mental health in many ways that we are just beginning to understand.2
According to the National Sleep Foundation, 40% of Americans sleep less than the recommended seven to nine hours of sleep a night.3
Chronic sleep deprivation may:
• Raise the risk of cardiovascular disease, depression, diabetes and obesity.
• Impair cognitive function, memory, and the immune system.
• Change metabolism, so that people eat more and store fat.
Not only is enough sleep a necessity, but the quality of sleep matters too. Deep, restorative, dreaming sleep is necessary for consolidating memories, learning, creativity, problem-solving, emotional well-being and physical development and repair.4
1. National Sleep Foundation. www.sleepfoundation.org/article/sleep-related-problems/fibromyalgia-and-sleep 2. American Sleep Association. www.sleepassociation.org/index.php?p=whatissleep 3. National Sleep Foundation, 2005 Sleep in America Poll. www.sleepfoundation.org/sites/default/files/2005_summary_of_findings.pdf 4. National Heart Lung Blood Institute. www.nhlbi.nih.gov/health/public/sleep/healthysleepfs.pdf
The National Institute of Health has published a document titled “Your Guide to Healthy Sleep.” This document provides information about sleep disorders such as snoring, sleep apnea, insomnia, restless leg syndrome, and narcolepsy.
Included in this document are the following tips about how to get a restful night’s sleep:
• Stick to a sleep schedule.
• Exercise is great but not too late in the day.
• Avoid caffeine and nicotine.
• Avoid alcoholic drinks before bed.
• Avoid large meals and beverages late at night.
• Avoid medicines that delay or disrupt your sleep, if possible.
• Don’t take naps after 3 p.m.
• Relax before bed.
• Take a hot bath before bed.
• Have a good sleeping environment.
• Have the right sunlight exposure.
• Don’t lie in bed awake.
• See a doctor if you continue to have trouble sleeping.
A more detailed explanation of these helpful tips can be found at www.nhlbi.nih.gov/health/public/sleep/healthysleepfs.pdf
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The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, do try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
0 = no chance of dozing
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
To check your sleepiness score, total the points. Check your total score to see how sleepy you are.
Adapted from the American Academy of Sleep Medicine http://yoursleep.aasmnet.org/SleepScale.aspx
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g. a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
SITUATION CHANCE OF DOZING
42
About.com www.backandneck.about.com
American Dietetic Association 800-877-1600 www.eatright.org
American Heart Association 800-242-8721 www.heart.org
American Psychiatric Association 888-357-7924 www.psych.org
American Sleep Apnea Association 202-293-3650 www.sleepapnea.org
American Sleep Association www.sleepassociation.org
Arizona Center for Integrative Medicine 520-626-6417 http://integrativemedicine.arizona.edu
Centers for Disease Control and Prevention 800-232-4636 www.cdc.gov/nccdphp/dnpa
The Chuckle Channel www.chucklechannel.com
Massachusetts General Hospital Benson-Henry Institute For Mind Body Medicine 617-643-6090 www.massgeneral.org/bhi
National Center for Complimentary and Alternative Medicine 888-644-6226 nccam.nih.gov
National Heart Lung and Blood Institute 301-592-8573 www.nhlbi.nih.gov
National Sleep Foundation 202-347-3471 www.sleepfoundation.org
Partnership to Fight Chronic Disease www.fightchronicdisease.org
Substance Abuse and Mental Health Services Administration 877-726-4727 www.samhsa.gov
Talk About Sleep 866-657-5337 www.talkaboutsleep.com
University of Massachusetts Medical School, Center for Mindfulness 508-856-2656 www.umassmed.edu/Content.aspx?id=41254
United States Department of Agriculture 202-720-2791 www.usda.gov
U.S. Department of Health and Human Services 877-696-6775 www.hhs.gov
WebMD www.webmd.com/back-pain/ chronic-back-pain-sleep
Resources for a Healthier You
Focus on Caregiving Most of us will find ourselves in the role of a caregiver or in need of a caregiver at some point in our lives. It may be taking care of a sick child, spouse, or perhaps a friend. Regardless of whom you are caring for or how you came to be a caregiver, the role is not an easy one.
The next few pages will address:
• Family Caregivers
• Caring for Those who Suffer from Pain
• Caring for Those at End of Life
Caring Conversations - English & Spanish
• Caring for the Caregiver
Tips for the Caregiver - English & Spanish
• Resources
Focus on Caregiving
44
Family Caregivers
What is a family caregiver?
According to the Department of Pain Medicine and Palliative Care at Beth Israel Hospital in New York, a family caregiver is “anyone who provides any type of physical and/or emotional care for an ill or disabled loved one at home.” For this definition, “family” refers to a nonprofessional who is called “family” by the person who is sick. Sometimes, family is whoever shows up to help.1
Caregivers can be:
• Parents
• Adult children
• Spouses
• Family members
• Neighbors
• Friends
Caregiver tasks can include any of the following:
• Helping with personal and/or medical care
• Household chores
• Assisting with transportation
• Overseeing finances
• Providing emotional support
1. Department of Pain Medicine and Palliative Care at Beth Israel Hospital, Caregiver Resource Directory www.netofcare.org/content/default.asp
45
Caring for Those who Suffer from Pain
Concerns about pain can be a source of distress for family caregivers. Many caregivers consider pain to be an indication of the patient’s status and equate worsening pain with advancing disease and impending death.1
Pain is subjective so it’s impossible to know what another person’s pain feels like. The important thing is to believe the care recipient when he/she reports pain. For a variety of reasons, people often don’t like to volunteer if they are in pain so don’t be afraid to ask. You can start by using some of the pain assessment tools in the first section of this Resource Guide.
Besides being the person experiencing pain, the next worst thing is for a caregiver to watch a loved one in pain. One way you can help is by acting as his/her advocate.
A few ways you can do this are by:
• Believing your loved one’s report of pain.
• Paying attention to the signs that indicate that your loved one might be in pain. These may include facial expressions, breathing and sighing heavily, unusual body movements, behavioral changes (such as not wanting to eat or sleep), or mental changes such as crying or irritability.
• Speaking up for your loved one when you go to the doctor, including insisting on managing his/her pain.2
1. Ferrell BR, Rhiner M, Cohen MZ, Grant M. “Pain as a metaphor for illness. Part I: Impact of cancer pain on family caregivers.” Oncol Nurs Forum. 1991;18(8):1303-9.
2. National Family Caregiver’s Association www.thefamilycaregiver.org/caregiving_resources/aapm.cfm
One way you can help a care recipient is by acting as his or her advocate.
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Caring For Those at End of Life
As a family caregiver, you may be involved in making serious medical decisions and having some very diffi-cult conversations. In light of this, no matter what your age or health condition, it is important to think about how you and your loved ones want to be cared for during the last months/days of your lives.
In preparing for this conversation some terms that you should be familiar with are:
• Informed consent • Palliative care
• Advanced directives • Hospice care
• Healthcare proxy • End of life care
• Living will
The Center for Practical Bioethics has developed a workbook called “Caring Conversations” that may provide the guidance you need to prepare you for this discussion. You can order hard copies by calling 1-800-344-3829. The workbook is available in English and Spanish and can be found on the following web pages:
www.practicalbioethics.org/documents/caring-conversations/ Caring-Conversations.pdf
www.practicalbioethics.org/documents/caring-conversations/ CC%20Spanish%20Print%20Copy%202008.pdf
47
Caring For the Caregiver
How to Support Someone Caring for Another
Many of us know someone who is a caregiver. Do you know someone who spends time providing physical, emotional or practical support to a family member or friend? Many caregivers feel alone, helpless, confused, unprepared, tired and unable to provide for the needs of their family member or friend. Often, people caring for another need help and do not know how to ask for it. 1
There are many ways to help support a caregiver...
Ask the caregiver how they are doing
Let them know you respect their privacy, but care about them and want to offer support and a listening ear.
Reach out to caregivers with a touch, a hug, or other physical expression of support
Supportive human contact is important and can be very meaningful to someone who is caregiving and experiencing the many losses that accompany being a caregiver. However it is always important to check with the caregiver to make sure they are okay with being touched.
Spend time with the person who is sick or injured
Family caregivers are often the only link the care receiver has with the outside world. Offering to spend time with the person can be a gift to both the care receiver and caregiver. Bring a book or newspaper to read aloud, a game to play, photos to share or just a friendly ear for a conversation.
Offer specific help
Saying “call me if you need me” is vague and may not appear to be a sincere offer for help. Often caregiv- ers do not want to be a bother or may not feel they have the time to make a call, as it is one more thing for them to do. Be specific, ask the caregiver if you can go shopping, make a phone call, cook a meal or sit with the person who is ill. By offering to do something specific, you are communicating that you are really willing to help the caregiver.
Tell the caregiver it is okay to take a break from their caregiving role
You can let them know that it is okay to take time to renew themselves; they deserve it and need to care for themselves in order to continue providing care.
1. National Hospice and Palliative Care Organization www.caringinfo.org/files/public/brochures/How_to_Support_Someone_Caring_for_Another.pdf
48Source: National Family Caregivers Association. Available at: www.thefamilycaregiver.org/pdfs/10_tips.pdf
Source: National Family Caregivers Association. Available at: www.thefamilycaregiver.org/pdfs/10_tips.pdf
10 10TIPS FOR FAMILY CAREGIVERS CONSEJOS
1 Caregiving is a job and respite is your earned right. Reward yourself with respite breaks often.
2 Watch out for signs of depression, and don’t delay in getting professional help when you need it.
3 When people offer to help, accept the offer and suggest specific things that they can do.
4 Educate yourself about your loved one’s condition and how to communicate effectively with doctors.
5 There’s a difference between caring and doing. Be open to technologies and ideas that promote your loved one’s inde-pendence.
6 Trust your instincts. Most of the time they’ll lead you in the right direction.
7 Caregivers often do a lot of lifting, pushing, and pulling. Be good to your back.
8 Grieve for your losses and then allow yourself to dream new dreams.
9 Seek support from other caregivers. There is great strength in knowing you are not alone.
10 Stand up for your rights as a care-giver and a citizen.
Para las Personas que Cuidan de un Familiar con una enfermedad crónica, incapacitado, o de edad avanzada
1 Cuidar de la salud de un familiar es un trabajo difícil y usted merece un respiro. Prémiese a sí mismo con pausas frecuentes.
2 Esté atento a los síntomas de depre-sión, y no demore en buscar ayuda profe-sional cuando la necesite.
3 Cuando la gente le ofrezca ayuda, acéptela y sugiera ideas específicas que ellos puedan realizar.
4 Edúquese sobre la condición de su ser querido y de cómo comunicarse en forma efectiva con los médicos.
5 Existe diferencia entre cuidar y hacer cosas para su ser querido. Acepte la tec-nología e ideas que promuevan la indepen-dencia del familiar de quien usted cuida.
6 Confíe en sus instintos. La mayoría de las veces le conducen en dirección correcta.
7 Lamente sus pérdidas y luego, dese la oportunidad de tener nuevos sueños y esperanzas.
8 Haga valer sus derechos como perso-na que cuida de un pariente incapacitado, de edad avanzada o con enfermedad cróni-ca, y como ciudadano.
9 Busque el apoyo de otras personas que estén en una situación similar a la suya. El saber que usted no está solo le da gran fortaleza.
10 Los protectores de salud con frecuen-cia levantan, empujan o halan cuando ayu-dan a su ser querido. ¡¡¡Cuide su espalda!!!
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American Chronic Pain Association 800-533-3231 www.theacpa.org
Center for Practical Bioethics 800-344-3829 www.practicalbioethics.org
Family Caregiver Alliance 800-445-8106 www.caregiver.org
Family Caregiving 101 www.familycaregiving101.org
Intercultural Cancer Council 713-798-4614 www.iccnetwork.org
Lance Armstrong Foundation 866-673-7205 www.livestrong.org
LotsaHelping Hands www.lotsahelpinghands.com
National Alliance for Caregiving www.caregiving.org
National Family Caregivers Association 800-896-3650 www.thefamilycaregiver.org
National Cancer Institute 800-422-6237 www.cancer.gov
National Hospice and Palliative Care Organization 800-658-8898 www.nhpco.org
Caregiver Resources
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Special Considerations for SeniorsWith the population aging, the need for information surrounding the unique needs of seniors with pain is increasing. Recognizing and communicating pain can be challenging but is not impossible.
The next couple of pages identify organizations and resources that address pain in the elderly from a patient, provider, caregiver and advocate perspective.
Special Considerations for Seniors
52
Special Considerations for Seniors
Pain in the absence of disease is not a normal part of aging, yet it is experienced daily by a majority of older adults in the United States.1 Given the growing population of people over the age of 65 (see graph below2) and studies supporting that elders are among the most undertreated for pain, it is important that attention focus on appropriately managing pain in this population.
According to the American Geriatric Society, pain is one of the most common complaints among older adults. Between 25 and 50% of older adults living at home, and up to 85% of those living in nursing homes, have significant pain. Most often, the pain is chronic or persistent, and associated with chronic medical condi-tions such as arthritis or cancer.
Pain can lead to other problems such as a decrease in mobility and the ability to do everyday activities. The sufferer may have trouble sleeping, experience “bad moods,” and develop a poor self-image. In addi-tion, people with pain often become anxious or depressed. They may be at greater risk for falls, weight loss, poor concentration, and difficulties with relationships.3
On the positive side, most pain can improve with treatment. Therefore, it is important to speak to your health care provider about all your pain issues and develop a treatment plan together.
Refer to Treatment Plan on page 19.
References:
1. Hanks-Bell M, Halvey K, Paice J. Pain assessment and management in aging. Online J Issues Nurs 2004;9. Available at: www.medscape.com/viewarticle/490773
2. Federal Interagency Forum on Aging-Related Statistics www.agingstats.gov./agingstatsdotnet/main_site/default.aspx
3. American Geriatric Society Foundation for Health in Aging www.healthinaging.org/aging-and-health-a-to-z/topic:pain-management
MILLIONS
100
90
80
70
60
50
40
30
20
10
01900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
PROJECTED
65 and over
85 and over
Population age 65 and over and age 85 and over, selected years 1900-2008 and projected 2010-2050
NOTE: Data for 2010-2050 are projections of the population. Refererence population: these date refer to the resident population. SOURCE: U.S. Census Bureau, Decennial Census, Population Estimates and Projections.
2008
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Ten Top Tips for Aging WellAccording to the American Geriatric Society Foundation for Health in Aging, simply living longer isn’t enough. What we really want is to live longer well, staying healthy enough to continue doing the things we love. It’s never too late to make changes that can help you live a longer and healthier life.
Here, from the American Geriatric Society Foundation for Health in Aging, are ten top tips for living longer and better:1
1 Eat a rainbow Eat brightly colored fruits and vegetables.
2 Sidestep Falls Walking as little as 30 minutes, three times a week can lower your risk of falls.
3 Toast with a smaller glass Drinking “moderately” changes with age - 1 drink a day for older men and ½ a drink a day for older women (a “drink” is 1 oz of hard liquor, 6 oz of wine, or 12 oz of beer).
4 Know the low-down on sleep in later life Most older people need 7 or 8 hours of sleep a night.
5 Sharpen your mind Complex computer games, discussion clubs, learning a new language and engaging in social give-and-take with other people can keep your brain sharp.
6 Enjoy safe sex More older people are being diagnosed with sexually transmitted diseases: use precaution.
7 Get a medications check Be sure your health care provider is aware of all medication you are taking including over-the-counter
medication, vitamins and any other supplements. *see page 23 of this Resource Guide
8 Speak up when you feel down or anxious Tell your health care provider right away if you have lingering sadness, tiredness, loss of appetite or
pleasure from doing the things you once enjoyed, difficulty sleeping, worry, irritability, and wanting to be alone much of the time.
9 Get your shots Must-have vaccines for seniors include those that protect against pneumonia, tetanus/diphtheria, shingles, and the flu.
10 Find the right health care professional and make the most of your visits See your health care professional regularly, answer his or her questions frankly, ask any questions you have, and follow his or her advice. *see page 16 of this Handbook
Adapted from the American Geriatric Society Foundation for Health in Aging www.healthinaging.org/files/documents/tipsheets/aging_well.pdf
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Alliance for Aging Research 202-293-2856 www.agingresearch.org
Alzheimer’s Association 800-272-3900 www.alz.org
American Association for Geriatric Psychiatry 301-654-7850 www.aagponline.org
American Association of Retired Persons 888-687-2277 www.aarp.org
American Geriatrics Society/Foundation for Health in Aging 800-563-4916 www.healthinaging.org
American Medical Directors Association 800-876-2632 www.amda.com
American Public Health Association 202-777-2742 www.apha.org
American Society of Consultant Pharmacists 800-355-2727 www.ascp.com
American Society on Aging 800-537-9728 www.asaging.org
Centers For Disease Control & Prevention 800-232-4636 www.cdc.gov
Families USA 202-628-3030 www.familiesusa.org
Federal Interagency Forum on Aging-Related Statistics www.agingstats.gov
Geriatric Pain 319-335-7080 www.geriatricpain.org
Gerontological Society of America 202-842-1275 www.geron.org
Leading Age 202-783-2242 www.LeadingAge.org
Medicare Rights Center 800-333-4114 www.medicarerights.org
National Academy of Elder Law Attorneys 703-942-5711 www.naela.org
National Association Directors of Nursing Administration in Long Term Care 800-222-0539 www.nadona.org
National Association of Area Agencies on Aging 202-872-0888 www.n4a.org
National Association of Nutrition and Aging Services Programs 202-682-6899 www.nanasp.org
National Committee to Preserve Social Security and Medicare 800-998-0180 www.ncpssm.org
National Council on Aging 202-479-1200 www.ncoa.org
National Hispanic Council on Aging 202-347-9733 www.nhcoa.org
National Indian Council on Aging 505-292-2001 www.nicoa.org
National Institute on Aging 800-222-4225 www.nia.nih.gov
National Senior Citizens Law Center 202-289-6976 www.nsclc.org
Resource Centers for Minority Aging Research 310-312-0536 www.rcmar.ucla.edu
Seniors Care Service www.ushc-online.org
Patient Resources
Focus on Clinical Trials
Slow enrollment of patients in clinical trials delays the evaluation of drugs, contributes to costs, and raises the financial risks of developing new drugs – but most importantly, delays in research can cost lives. Participating in medical research can be an invaluable contribution to helping to identify new treatments and even cures. However, there are also risks that must be carefully considered, together with your health care provider.
This section provides a basic overview of clinical trials. Points to keep in mind if you are thinking about volunteering for a clinical trial, include:
• Whatisaclinicaltrial?
• Whocanparticipateinclinicaltrials?
• Whatisinformedconsent?
• Samplequestionstoaskyourprovideraboutparticipatinginclinicaltrials
• Resourcesformoreinformationaboutparticipatinginclinicaltrails
Focus on Clinical Trials
56
Research into new ways to treat pain provides more than just new options. It gives people who suffer from pain hope. In the forefront of pain research are scientists supported by the National Institutes of Health (NIH), including the National Institute of Neurological Disorders and Stroke. Other institutes at NIH that support pain research include the National Institute of Dental and Craniofacial Research, the National Cancer Institute, the National Institute of Nursing Research, the National Institute on Drug Abuse, and the National Institute of Mental Health. Developing better pain treatments is the primary goal of all pain research being conducted by these institutes.1
To make better progress against a disease or illness, however, more patients must enroll in clinical trials. There are many promising new agents, which need to be tested as single agents, but also within existing protocols. However, the pool of patients considering clinical trials remains very low, and studies failing to reach enrollment goals are increasing as the number of promising agents increase.2
What is a Clinical Trial?
A clinical trial (also clinical research) is a research study in human volunteers to answer specific health questions. Carefully conducted clinical trials are the fastest and safest way to find treatments that work in people and ways to improve health. Interventional trials determine whether experimental treatments or new ways of using known therapies are safe and effective under controlled environments. Observational trials address health issues in large groups of people or populations in natural settings.
Who Can Participate in Clinical Trials?
All clinical trials have guidelines about who can participate. Inclusion/exclusion criteria are the medical or social standards determining whether a person may or may not be allowed to enter a clinical trial. These criteria are based on such factors as age, gender, the type and stage of a disease, previous treatment history, and other medical conditions. It is important to note that these criteria are not used to reject people personally, but rather to identify appropriate participants and keep them safe. Inclusion/exclusion criteria, which will vary by study, are an important principle of medical research that helps to produce reliable results. The factors that allow someone to participate in a clinical trial are called “inclusion criteria” and those that prevent someone from participating are called “exclusion criteria.”
Before joining a clinical trial, a participant must qualify for the study. Some research studies seek partici-pants with illnesses or conditions to be studied in the clinical trial, while others need healthy participants. The inclusion/exclusion criteria help ensure that researchers will be able to answer the questions they plan to study.
Understanding Informed Consent
Millions of volunteers participate in government- and industry-sponsored clinical trials each year. Prior to agreeing to participate, every volunteer has the right to know and understand what will happen during a clinical trial. This is called inform- ed consent and it is a process that can help you decide whether or not participating in a trial is right for you. CenterWatch has created a brochure called “Understanding Informed Consent” that can be downloaded through their website:
www.centerwatch.com/clinical-trials/understanding-informed-consent.aspx
1. National Institute of Neurological Disorders and Stroke. “Pain: Hope through Research.” www.ninds.nih.gov/disorders/chronic_pain/detail_chronic_pain.htm#175133084 Accessed July 6, 2012.
2. Patients Against Lymphoma, Patient Participation in Clinical Trials. www.lymphomation.org/clinical-trials-participation.htm Accessed May 30, 2012.
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What questions should be asked before choosing to participate?
Patients considering participating in a clinical trial should talk about it with their health care providers. Potential volunteers should also understand the credentials and experience of the staff and the facility involved in conducting the study.
Questions to ask a physician or medical caregiver:
• How long will the trial last?
• Where is the trial being conducted?
• What treatments will be used and how?
• What is the main purpose of the trial?
• How will patient safety be monitored?
• Are there any risks involved?
• What are the possible benefits?
• What are the alternative treatments besides the one being tested in the trial?
• Who is sponsoring the trial?
• Do I have to pay for any part of the trial?
• What happens if I am harmed by the trial?
• Can I opt to remain on this treatment, even after termination of the trial?
SOURCE: CenterWatch. “Volunteering for a Clinical Trial.” www.centerwatch.com/clinical-trials/volunteering.aspx Accessed July 6, 2012.
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Your health care provider may ask you about participating in a clinical trial. If you find information on a clinical trial that you are considering volunteering for, make sure that you discuss this with your provider. Making the decision to volunteer for medical research is an important one, and made after evaluating all the potential risks and benefits. The following websites provide more information about clinical trial participa-tion and the status of pain-related studies.
ClinicalTrials.gov
ClinicalTrials.gov is a registry and results database of federally and privately supported clinical trials conducted in the United States and around the world. ClinicalTrials.gov provides information about a trial’s purpose, who may participate, locations, and phone numbers for more details. ClinicalTrials.gov currently has more than 126,000 trials with locations in 179 countries, and lists information about more than 11,000 trials related to pain. For more information, visit www.clinicaltrials.gov.
CenterWatch
CenterWatch lists more than 80,000 active clinical trials seeking study volunteers each month, involving new drugs and devices regulated by the FDA and the Department of Health and Human Services. There are currently more than 1,100 clinical trials underway for pain and pain-related conditions across the country. Listings are posted across a wide range of medical conditions and are searchable by therapeutic area, dis-ease or geographic location. For more information, visit www.centerwatch.com.
MedlinePlus
MedlinePlus is a web-based information service from the National Library of Medicine. Its “Health Topics” section has extensive information from NIH and other trusted sources on hundreds of diseases and condi-tions, including a link to clinical trials. It also includes an informative “Clinical Trials” health topic page, with material in Spanish, and an interactive tutorial on clinical trials. For more information, visit www.nlm.nih.gov/medlineplus/clinicaltrials.html.
The National Heart, Lung and Blood Institute
The National Heart, Lung and Blood Institute offers more information and videos about the importance of including children in clinical trials. For more information, visit www.nhlbi.nih.gov.
The Patient Advocate Foundation
The Patient Advocate Foundation offers information about clinical trials through its publication, “Lighting the Way: A Practical Guide to Clinical Trials,” which can be accessed here: www.patientadvocate.org/index.php?p=674.
Resources for Clinical Trials Information
Focus on FinancesAccording to the Institute of Medicine, the annual cost of chronic pain in the U.S. is estimated to be a staggering $560-635 billion, including health care expenses and lost productivity.1
On a personal level, we also know that people with pain can face significant financial hardship in paying for care, particularly if pain has limited abilities to work.
This section includes helpful resources including:
• Tipsoncommunicatingwithinsurancecompanies
• Waystobetterunderstandinsurancecoverage
• Linkstotoolstohelpwithinsurancecompanyappeals
• Resourcesforpatientassistanceprograms,Medicare,Medicaid,active-dutymilitaryandveterans,and workers’ compensation
1.IOM(InstituteofMedicine).2011.RelievingPaininAmerica:ABlueprintforTransformingPrevention,Care,Education,andResearch.Washington,DC: TheNationalAcademiesPress.
Focus on Finances
60
Health Care Expenses
Currently, health care expenses are financed through one or a combination of ways, based on circumstances and eligibility. These include private health insurance, Medicare or Medicaid, state-based workers’ compen-sation programs or active-duty military or Veterans Health Administration.
Within each of these programs, there are an often overwhelming array of policies, regulations and proce-dures that dictate coverage of pain treatments. As you’re likely aware, just because a physician recommends a certain course of treatment or medication does not mean that an insurer will cover those costs. For people with pain and their caregivers, this may mean that you have to work harder to ensure access to benefits that you are entitled to through appeals or working to change policies.
By understanding how your insurance plan operates, you may be in a better position to advocate for im-proved pain care. It is also important to be aware of cost-saving strategies that insurers use that may affect pain treatment. Caregivers and health care professionals can also advocate for improved access on behalf of themselves and their loved ones.
Insurance Information
ID #:
Phone number:
Case manager/PT navigator:
Pre-approval:
Date called:
Name of representative:
Response:
Action:
61
Communicating Effectively with Insurance Company Personnel
Talking with Insurance Personnel
Before you pick up the phone to speak to a claims representative, you need to gather some information. Be prepared to give the person you talk with:
• Your name and your relationship to your care recipient
• Your care recipient’s birth date
• The insurance policy number
• The name and address of the organization that sent the bill
• The total amount of the bill
• The diagnosis code on the bill
• The Explanation of Benefits (if you are questioning an insurance payment).
When you start the conversation, ask for the name and telephone extension of the individual who is handling your phone call. If you need to call again, you will want to try to speak with the same person.
Keep in mind that billing office personnel and insurance claims representatives are there to serve you. You are the customer. Be assertive. You should expect to:
• Be treated with respect and consideration.
• Have your concerns clarified.
• Have your questions answered with accurate and timely information.
• Be informed of any steps you need to take to move things along.
Communication TipsHere are some tips for communicating effectively with people who work in the health insurance system.
• Be Prepared. Before you call an insurance company, write down a list of the questions you have so you can handle everything in one phone call.
• Take Good Notes. Take notes about your phone conversations, including the date of the call and the information you were given.
• Be Clear and Concise. State clearly and briefly what your question or concern is, what you need, and what you expect.
• Be Patient. Health insurance issues are frustrating and time-consuming. Accept that you will spend a certain amount of time navigating through automated telephone menus, waiting on hold and waiting for the claims process to be completed.
• Be Considerate. Most insurance personnel want to do their jobs well, and they have a tough job to do. Thank them when they have been helpful. Speak to them kindly. Assume that they are trying to help you, not that they are “the enemy.”
Source: National Family Caregiver Association. http://www.thefamilycaregiver.org/caregiving_resources/v1_a8.cfm. Accessed July 6, 2012.
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The Patient Advocate Foundation
The Patient Advocate Foundation (PAF) has created several brochures that will give you a better understand-ing of your insurance plan as well as discuss the cost of health care treatments with your provider. For more information, go to: www.patientadvocate.org.
http://www.patientadvocate.org/requests/publications/GU-Healthcare-Costs-For-Patients.pdfhttp://www.patientadvocate.org/requests/publications/GU-Understanding-Insurance-Plan.pdf
Resources for Medicare Beneficiaries
The National Pharmaceutical Council (NPC) has developed “Resources for Medicare Beneficiaries: Using Your Medicare Drug Plan – What to Do if Your Medicine Isn’t Covered.”
This 12-page publication helps Medicare Part D recipients and caregivers understand some of the challenges involved in navigating the Medicare prescription drug system, such as:
• How to request coverage of medication under a particular Medicare plan
• When to appeal if a Medicare plan denies coverage of a particular medication
• How to determine who will serve as an appointed representative
• The steps to follow in the appeal process
This brochure includes a sample letter of appeals for Medicare beneficiaries and is also available in Spanish. For more information, visit: www.npcnow.org.
The National Council on Aging and Access to Benefits Coalition have created the resource, “My Medicare Matters.” This website offers information about Medicare, considerations when selecting or switching a Medicare Part D prescription benefit plan, and staying healthy. More information can be found at: www.mymedicarematters.org.
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Active Duty Military & Veterans
Since February 1998, TMA leadership has managed the TRICARE health care program for active duty members and their families, retired service members and their families, National Guard/Reserve members and their families, survivors and others entitled to Department of Defense medical care. For more information, visit www.tricare.mil.
The Veterans Administration offers comprehensive health care and other benefits for veterans and dependents of active-duty, retired or deceased members of the military. Call 1-800-827-1000 or visit www.va.gov for more information.
Workers’ Compensation
The Workers’ Compensation Administrators Directory lists Workers’ Compensation home page links for all 50 states and the District of Columbia. This can be found here:
www.casemanagement.com/casemanagers/reference/ workerscomp-administrators.html
64
Centers for Medicare & Medicaid Services 800-633-2273 www.cms.hhs.gov
National Council on Aging & Access to Benefits Coalition www.mymedicarematters.org
National Pharmaceutical Council 202-827-2100 www.npcnow.org
Partnership for Prescription Assistance 888-477-2669 www.pparx.org
Patient Advocate Foundation 800-532-5274 www.patientadvocate.org
RxAssist 401-729-3284 www.rxassist.org
Social Security 800-772-1213 www.ssa.gov/prescriptionhelp
Together Rx Access 800-444-4106 www.togetherrxaccess.com
TRICARE North Region 877-874-2273 South Region 800-5445 West Region 888-874-9378 www.tricare.mil
U.S. Department of Veterans Affairs 202-225-9756 www.va.gov
State Medicaid Website Addresses
Alabama www.medicaid.alabama.gov
Alaska www.hss.state.ak.us/dhcs
Arizona www.ahcccs.state.az.us
Arkansas http://humanservices.arkansas.gov/ Pages/default.aspx
California www.dhs.ca.gov
Colorado www.chcpf.state.co.us
Connecticut www.dss.state.ct.us/dss.htm
Delaware www.DMAP.state.de.us
District of Columbia www.doh.dc.gov
Florida www.fdhc.state.fl.us
Georgia www.dch.georgia.gov
Hawaii http://hawaii.gov/health
Idaho www2.state.id.us/dhw
Illinois www2.illinois.gov/hfs/Pages/default.aspx
Indiana www.in.gov/fssa
Iowa www.dhs.state.ia.us
Kansas www.srskansas.org
Kentucky www.chfs.ky.gov
Louisiana www.dhh.state.la.us
Resources to Assist People Facing Financial Challenges
65
Maine www.maine.gov/dhhs
Maryland www.dhmh.state.md.us
Massachusetts www.mass.gov
Michigan http://michigan.gov/mdch
Minnesota www.dhs.state.mn.us
Mississippi www.medicaid.ms.gov
Missouri www.dss.mo.gov/mhd/index.htm
Montana www.dphhs.mt.gov/programsservices/ medicaid.shtml
Nebraska http://dhhs.ne.gov/Pages/default.aspx
Nevada www.dhcfp.state.nv.us
New Hampshire www.dhhs.state.nh.us
New Jersey www.state.nj.us/humanservices
New Mexico www.hsd.state.nm.us
New York www.health.state.ny.us
North Carolina www.dhhs.state.nc.us/dma
North Dakota http://lnotes.state.nd.us/dhs/dhsweb.nsf
Ohio www.state.oh.us/odjfs/ohp
Oklahoma www.okhca.org
Oregon www.oregon.gov/DHS/healthplan
Pennsylvania www.dpw.state.pa.us
Rhode Island www.dhs.ri.gov
South Carolina www2.scdhhs.gov
South Dakota www.state.sd.us/social
Tennessee http://health.state.tn.us
Texas www.government.texasonline.state.tx.us
Utah http://health.utah.gov/medicaid
Vermont http://ovha.vermont.gov
Virginia www.dmas.virginia.gov
Washington http://hrsa.dshs.wa.gov
West Virginia www.wvdhhr.org
Wisconsin www.dhfs.state.wi.us
Wyoming http://health.wyo.gov
Resources to Assist People Facing Financial Challenges
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In the Face of Pain®
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the handbookfor people with pain a resource guide 3rd edition